Attacks on doctors’ incomes unfounded and out of control

The British Columbia auditor general recently issued a report that questioned the “cost-effectiveness” of physicians in the health system. His simplistic, impractical recommendations are reminiscent of other government bureaucrats, who look upon doctors as conscripted civil servants rather than professionals. As Canadian Medical Association president in 2007, I wrote to all auditors general in Canada asking them why our health system (responsible for more than 40% of most provincial budgets) is rated last in value for money when compared with 29 European countries. The responders replied they did not have the resources to study the issue.

Physician surveys reveal that about 75% favour a payment scheme that is not pure fee for service.

Many would embrace a 35- to 40-hour week with benefits, overtime and holiday pay, sick and educational leave, sabbaticals and pensions similar to those that civil servants with similar educational levels receive. The reality is that governments prefer the sweatshop (a term from the English Industrial Revolution) approach, relying on piecework to deliver low-cost products or services to consumers, while placing heavy demands on workers who provide cheap, efficient labour to the employer.

In the non-medical world, markets influence value and worth. Lawyers will pay doctors far more for describing surgery than government pays for performing it. A Vancouver realtor sold three houses last week, earning $450,000. The fee for a weekend visit by a plumber to inspect a copper pipe is double that of a urologist to inspect a urethral pipe. A British professional soccer player just negotiated a salary of $500,000 a week. I previously operated on his teammate, who recognized (as did his agent and team) the value of a successful outcome.

Rewarding excellence

It is true that one cannot easily put a price on saving a life, or restoring the ability to walk or read, but governments have gone too far, and are harming patients, by eliminating virtually all rewards for excellence, expertise, efficiency and productivity.

We have allowed paternalistic control by government. Our office expenses depend on the free market, but in generating revenue we are conscripted workers. In accepting educational grants, malpractice premium supplements and retirement funding, we succumb to that state and give up flexibility in managing our own resources.

In 1944, when the average British Columbia worker made 91 cents per hour, an orthopedic surgeon’s fee for treating osteomyelitis was $300. Based on inflation, the equivalent fee today would be $6,150 (current fee is $183). The cost of a Vancouver detached house then was about $4,000; today it varies from $900,000 to $2 million. In 1981, the arthroscopic meniscectomy fee in B.C. was $294. Based on inflation it would now be $771 (current fee is $280).

My examples are from orthopedics, but similarities exist in other specialties and explain why young doctors lag behind their predecessors in their ability to pay off debts or purchase a home. Canadian Institute for Health Information figures reveal that doctors’ gross revenues (before overhead and staff) represent 15% of total health expenditures in Canada. In 1987 the figure was 15.7%. It is mathematically and historically wrong to blame doctors’ remuneration for rising costs.

Governments know that our current system is unsustainable. We must consider an alternative to the “cap in hand” approach to negotiating with governments that blame us for their ineptitude in managing the health system. The introduction of competition and market forces will force governments to engage in long-term, rather than three- to four-year planning. This year our constitutional challenge will succeed in forcing much needed transformation. We will achieve what hundreds of Canadian health commissions have failed to do. Learn more at our website www.charterhealth.ca.

Brian Day is a Vancouver-based orthopedic surgeon who served as president of the CMA in 2007/08.